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Tuesday, November 5, 2013

Don’t Ask Who’s to Blame, Ask What’s to Blame

We recently came across a blog from a local newspaper outlet
that we read with interest and not a little dismay. The blog highlights how one of the major regulators in the state, the California Public
Utilities Commission, is trying to change its safety culture following a major
disaster in the area that it was at least partly responsible for, according to
critics. As part of the effort to change its culture the regulator was going to
hire consultants to help in the process. The blog is critical of this process,
quoting others who point to failed leadership as the root cause, with the fix
being “replacing the commission’s brass” as a quick way to change the culture.

Now, we have to say that we’re probably not an unbiased
observer on the issues related to hiring consultants, so we won’t speak to that
aspect of the blog. However, the implication of much of the blog is that the
problems are poor leaders and if we only just replaced those leaders we wouldn’t
have any more problems. This line of reasoning is common, flawed, and
potentially dangerous.

In response to the killing of three civil rights workers
Martin Luther King Jr. cautioned those who wanted justice to not ask who is to
blame. Rather, they should ask what is to blame. King knew that if the only
thing that resulted from these heinous murders were a few Ku Klux Klan members
going to jail there would be no significant long-term benefit. People who were
just as bigoted as the others would replace anyone they sent to jail and the
problems would perpetuate. The problem isn’t the people, it’s the system that
creates the people and allows them to act as they did.

King’s wisdom rings true in so many areas. We often times
look for people to blame without considering that it might be the system that
needs fixing. The problem is that it makes sense to blame people - it’s easier
to just fire someone or tell them to do better next time rather than admit that
the system is broken. It’s also a lot scarier to believe that the system is
broken. Consider a case of malpractice in medicine – isn’t it scarier to think
that the problem is due to a broken healthcare system rather than just a bad
doctor?

And in this case, it’s so much more comforting to blame the
problem on a few bad apples within the regulatory agency rather than to
consider that the people operating in that agency may have to face complex and
competing goals every day. The problem of course is that when we just blame the
people in the system without trying to fix the system we’re accepting that
we’ll run into similar problems in the future because eventually the same
pressures that allowed mistakes to be made will push others too close to the
edge and we’ll face another disaster with more innocent people suffering.

So, if we truly want justice, accountability,
and safety then we need to stop having knee jerk reactions to these kinds of
events. We need to ask ourselves not who we need to blame, but what is to blame
– what in the interaction between the people in the system and the system
itself allowed these mistakes to be made and how can we fix that to ensure that
these kinds of disasters never happen again.